A 65-Year-Old Man Comes to the Physician to Discuss Chronic

question 546

Multiple Choice

A 65-year-old man comes to the physician to discuss chronic obstructive pulmonary disease.  His medications include budesonide/formoterol, tiotropium, and as-needed albuterol.  He has dyspnea on exertion after walking 100 yards or up a flight of stairs.  The patient has never had an exacerbation requiring hospitalization.  He quit smoking 7 years ago and has a 45-pack-year history.  SaO₂ is 88% on room air at rest.  He has a barrel chest, and the lung examination shows decreased air entry bilaterally but is otherwise clear to auscultation.  Heart examination is significant for a holosystolic murmur at the left lower sternal border and a loud P2.  There is 1+ bilateral pretibial edema.  Pulmonary function results are as follows:

An echocardiogram demonstrates normal left ventricular function, normal right ventricular size and function, and moderate tricuspid regurgitation.  Estimated pulmonary artery systolic pressure is 50 mm Hg, and mean pulmonary artery pressure is 29 mm Hg.
In addition to starting home oxygen, which of the following would be recommended in this patient?

• A)No additional therapy
• B)Right heart catheterization followed by bosentan
• C)Right heart catheterization followed by inhaled iloprost
• D)Sildenafil
• E)Warfarin

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